Surgery and Perioperative Intralesional Corticosteroid Injection for Treating Earlobe Keloids: A Korean Experience

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1 Ann Dermatol Vol. 21, No. 3, 2009 ORIGINAL ARTICLE Surgery and Perioperative Intralesional Corticosteroid Injection for Treating Earlobe Keloids: A Korean Experience Jin Young Jung, M.D., Mi Ryung Roh, M.D., Yeon Sook Kwon, M.D., Kee Yang Chung, M.D., Ph.D. Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea Background: The aesthetic implications of ear keloids, which affect people of all races, are serious and the treatment of earlobe keloids is known to be difficult. The high rate of recurrence following excision alone has led to investigating various types of adjuvant therapy, including intralesional corticosteroid injection. Objective: We evaluated the efficacy of excision combined with perioperative intralesional triamcinolone acetonide injection for treating earlobe keloids of Korean patients. Methods: From 1997 to 2006, eighteen keloids on the earlobes of fifteen Korean patients were treated. The patient age ranged from 15 to 32 years (mean age: 24 years). All the patients were female and the keloids occurred after ear piercing. Preoperative intralesional triamcinolone acetonide (TA) injection was administered twice at a 1-month interval. Postoperative intralesional TA injections were given every 1 month for several months, depending on the patient s clinical progress. Results: The follow-up period ranged from 4 to 42 months (mean: 18.5 months). After the surgery, TA intralesional injections were given 2 to 13 times (mean: 5.2 times). Of the treated keloids, eleven showed good results (61.1%) and three recurred (16.6%). No complications from the TA intralesional injection were observed. Conclusion: Among the various treatments for earlobe keloids, we suggest that excision with corticosteroid intralesional injection can be used as the first line therapy when considering its effect and economic advantage. (Ann Dermatol 21(3) , 2009) Received July 4, 2008, Accepted for publication September 22, 2008 Reprint request to: Kee Yang Chung, M.D., Department of Dermatology, Yonsei Medical Center, Yonsei University College of Medicine, 134, Sinchon-dong, Seodaemun-gu, Seoul , Korea. Tel: , Fax: , kychung@yuhs.ac -Keywords- Earlobe keloid, Excision, Intralesional injection, Triamcinolone acetonide INTRODUCTION Keloids are benign, hard and persistent fibrous proliferations that develop in predisposed persons at sites of cutaneous injury 1-3. Keloids of the ear usually appear as shiny, smooth and globular growths on one or both sides of the ear. They are usually preceded by ear piercing, trauma or burns 1,2. The incidence of keloid formation is difficult to assess as it varies from 4.5% to 16% in the Black and Hispanic populations 4,5. The incidence of keloid in dark-skinned people is estimated to be 3 to 20 times that of light-skinned people 1,5-7. In some cases, nonsurgical therapies such as intralesional corticosteroids 8, X-ray irradiation 9, pressure dressing 10, silicone gel sheets 11, cryotherapy 12 and interferon 13 were reported to be effective to treat keloids. However, even though the size of the keloid may decrease with nonsurgical treatment alone for the cases of larger lesions, the results may not be cosmetically satisfactory. Various surgical methods such as excision followed by primary suture 14, healing by secondary intention 15, skin graft 16 or local flap 17 have been used. Yet surgical excision alone has shown varying degrees of success and perioperative nonsurgical therapies should be combined to prevent the inevitable recurrence after surgical excision. The purpose of this study was to study the usefulness of a combination of surgical excision and perioperative corticosteroid intralesional injection, which is a very economical treatment that patients will comply with, for the treatment of earlobe keloids in an Asian population. Vol. 21, No. 3,

2 JY Jung, et al MATERIALS AND METHODS Patients From 1997 to 2006, eighteen earlobe keloids in fifteen Korean patients were treated with our protocol. The patients ages ranged from 15 to 32 years (mean age: 24 years). All the patients were female and the keloids occurred after ear piercing. At the time of treatment the lesions have been present from 8 to 60 months (mean: 28.7 months). Seven patients had keloids on the left ear and five patients had keloids on the right ear. Three patients had bilateral lesions. The size of the keloids ranged from 0.25 to 3 cm 2 (mean: 1.25 cm 2 ). Among the fifteen patients, eight patients had received prior treatments with intralesional corticosteroid injection and one patient had received excision (Table 1). Methods Preoperative intralesional triamcinolone acetonide (TA) injections were administered twice at a 1-month interval. A total of 0.1 to 1.0 ml of TA (20 40 mg/ml) was decided upon depending on the size and the activity of the lesions. The surgery was performed under local anesthesia with using 1% lidocaine and 1:100,000 epinephrine. An incision was done within the edge of the keloid. The marginal skin of the overlying keloid, which consisted of epidermis and the thin dermis overlying the keloid, was raised from the fibrous keloid core. The fibrous keloid core was completely removed after completely raising the marginal skin. After trimming the redundant marginal skin, the defects were resurfaced using the marginal skin of the overlying keloid. All the wounds were closed with using one layer of 6-0 Ethilon without tension. A simple dressing was applied after surgery. The postoperative intralesional TA injection was started at a 2 week time point after surgery and an injection was given every 1 month for several months, depending on the patient s clinical progress, and a total of 0.1 to 1.0 ml of TA (20 40 mg/ml) was also decided upon depending on the size and the activity of the remaining lesions. The final results were judged during the postoperative follow-up period. A good result was defined as a normalappearing, flat scar that needed no further aesthetic refinement. A fair result was defined as a flat scar without recurrence, but aesthetic refinement was needed. Recurrence was defined as any indurated papule or nodule extending beyond the borders of the healed scar line of the previously excised lesion. RESULTS The follow-up period ranged from 4 to 42 months (mean: 18.5 months). After the surgery, TA intralesional injection was performed from 2 to 13 times (mean: 5.2 times). Among the treated keloids, 11 showed good results (Fig. 1), 4 showed fair results and 3 recurred (Table 1). We Table 1. Patients summary Case Sex/Age Duration (months) Site Size (cm 2 ) Previous treatment Postoperative TA ILI Postoperative follow-up (months) Result 1 F/28 48 Right G 2 F/24 12 Left TA ILI 6 8 F 3 F/24 39 Right F 4 F/15 24 Right G Left G 5 F/32 48 Left G 6 F/24 60 Left TA ILI 4 4 R 7 F/28 36 Right Excision 2 21 G 8 F/16 8 Right G 9 F/23 24 Right G Left G 10 F/24 36 Left TA ILI 6 12 G 11 F/22 12 Left TA ILI 3 28 G 12 F/19 36 Left TA ILI 6 23 F 13 F/23 24 Left TA ILI 3 45 G 14 F/29 11 Right TA ILI 3 40 F 15 F/24 12 Right TA ILI 3 21 R Left TA ILI 3 21 R TA ILI: intralesional injection of triamcinolone acetonide, G: no recurrence of keloid and good aesthetic results, F: no recurrence of keloid and fair aesthetic results, R: recurrence 222 Ann Dermatol

3 Surgery and Perioperative Intralesional Corticosteroid Injection for Treating Earlobe Keloids: A Korean Experience Fig. 1. (A) Patient 4 s earlobe keloid before treatment and (B) 6 months after surgery. (C) Patient 11 s earlobe keloid before treatment and (D) 3 months after surgery. performed dermabrasion on the lesions with fair results. For case 6, an earlobe keloid recurred about 4 months after the surgery. Preoperative intralesional TA injection was administered twice at a 1-month interval and postoperative intralesional TA injections were done 4 times every 1 month. Yet the lesion enlarged during the course of performing the postoperative intralesional TA injections. After the recurrence, the patient did not revisit our clinic and we could not provide further treatment for her recurred earlobe keloid. For case 15, both earlobe keloids recurred about 8 months after surgery. She wanted to be transferred to another clinic due to personal reasons and we recommended regular intralesional TA injections every 1 month. For cases 10 and 12, indurated papules on the healed scar line occurred 1 month after the surgery. We treated the indurated papules with intralesional TA injection twice at a 1-month interval and the indurations were resolved. Any adverse effects such as atrophy and telangiectasia were not observed at and around the injection sites. DISCUSSION Keloid development has been associated with different types of skin injury, including surgery, ear piercing, laceration, burn, vaccination or inflammatory processes 1,2. With an ever-expanding number of patients undergoing body piercing, dermatologists are increasingly being consulted for the treatment of ear keloids. Multiple therapeutic options are available for the treatment of keloids. Combination therapy appears to be the most effective, although few previous studies have compared the various regimens. Excision alone of keloids has been associated with recurrence rates of 45% to 100% 18,19. Numerous treatments after excision have been used such as postexcisional injections of corticosteroids 8 or interferon 13, radiotherapy 9, pressure splints 10 and silicone sheeting 11. In a large review of the literature, Friedman 20 proposed surgical excision and corticosteroids for small keloids, pressure therapy and a combination of surgery and steroid for moderately large scars and a combination of surgery and postoperative radiotherapy for very large, resistant scars. Earlier studies have shown that postexcisional TA injection is associated with a recurrence rate of 0% to 100%, but the majority of studies reported less than a 50% recurrence rate 18. The recurrence rate in our study was 16.6%. Berman and Flores 13 reported a recurrence rate of 18.7% when interferon alpha-2b injections were given after keloid excisions. Their result was lower than the recurrence rate achieved with excision alone (51%) or a combination of excision and postoperative triamcinolone intralesional injection (58%). Although the recurrence rate Vol. 21, No. 3,

4 JY Jung, et al Table 2. Keloid treatment using surgery and intralesional TA injection in the literature Study (year) Number Age (years) Site Follow-up (months) Recurrence (%) Singleton and Gross 25 (1971) (12 58) Ear 12 4 (7%) Kiil 26 (1977) 15 - Whole body (86.7%) Barton 27 (1978) 19 - Ear (0%) Shons and Press 8 (1983) (13 19) Ear 35 (12 62) 1 (3%) Salasche and Grabski 28 (1983) (16 22) Ear >12 0 (0%) Sclafani et al. 23 (1996) 12 - Ear 19 4 (33.3%) Berman and Flores 13 (1997) 65 - Whole body (58.5%) Our study (2007) (15 32) Ear 28.7 (4 42) 3 (16.6%) of interferon injection after excision is known to be low, interferon treatment is more expensive than TA intralesional injection and the results are similar to ours. Recurrence rates of as low as 2%, but up to 50%, have been reported following postoperative external-beam radiotherapy 21,22. A randomized controlled trial of earlobe keloid excision followed by either intralesional steroid injection or radiotherapy has shown that radiotherapy has a lower recurrence rate than that of steroid injection, a statistically significant difference was not observed 23. Although surgical excision combined with radiotherapy has shown fairly successful results in treating resistant keloids, many surgeons are still reluctant to use ionizing radiation for the treatment of benign diseases. Surgery followed by pressure treatment has shown a good response rate of %, and especially after excision of earlobe keloids 10. However, the pressure must be maintained day and night for a minimum of 6 9 months, and premature release is frequently followed by recurrence of the lesion. Topical silicone sheets have been shown to soften scars and reduce itching, and children like this treatment because the gel-sheeting is painless. It usually takes 6 12 months of therapy to achieve the best results, but most patients become noncompliant after several months because of the treatment s duration and the inconvenience of cutting and placing the silicone gel-sheeting on the keloid 11. The postsurgical use of imiquimod 5% cream has recently been reported 24. All 4 patients were successfully treated without recurrence for 12 months after their final excision. Although imiquimod 5% cream following tangential shave excision was effective, most patients experienced mild to marked irritation secondary to the daily application. Those with marked irritation will sometimes have to discontinue the medication for several days to a week. The patients who have large surgical sites and wounds closed with flaps, grafts or tension should not start imiquimod cream therapy for four to six weeks postoperatively because early application often causes the surgical site to splay or dehisce. The use of steroid injections as an adjunctive procedure after keloid excision had been reported with using various dosages, schedules and concentrations of drug. When excision was combined with postoperative intralesional triamcinolone acetonide injection, the recurrence rates were % (Table 2) 8,13,23, Table 2 showed that the recurrence rates (0 33.3%) for the ear keloids were lower than those for keloids other sites and our study showed a 16.6% recurrence rate. Shons and Press 8 reported that only 3% of earlobe keloids recurred after excision and three injections of 40 mg/ml triamcinolone at a 4 week interval and beginning 3 weeks postoperatively. Singleton and Gross 25 reported on the treatment of auricular and lobular keloids using a posterior approach for excision followed by steroid injection at immediately postoperative period. Steroid injections were then continued at a 1-month interval postoperatively for 1 year. For the 21 patients who were followed for more than one year, there were 13 good results and 2 recurrences. For the 33 patients who were followed for less than one year, 24 showed good results and 2 recurred. The corticosteroid inhibits alpha2-macroglobulin, which in turn inhibits collagenase. Once this pathway is blocked, collagenase is elaborated, thus enabling collagen degeneration 29. The risk of relapse following these treatments depends on local wound-related factors and general patient-related factors. A high recurrence rate is seen at sites where have keloids developed after tensioned wound closure, wound infection and dehiscence. Patients with a positive family history and a past history of recalcitrant keloids with prior treatment failures are at a greater risk of recurrence 30. The high rate of recurrence following excision alone has led to the investigation of many different types of adjuvant therapy, but of these techniques has been demonstrated to be optimal. Until one strategy is shown to be clearly superior, the choice of adjuvant treatment needs to be tailored to the individual patient and the clinical situation. Although various treatments after surgery have previously been used, we think that excision with corticosteroid 224 Ann Dermatol

5 Surgery and Perioperative Intralesional Corticosteroid Injection for Treating Earlobe Keloids: A Korean Experience intralesional injections can be used as the standard treatment for earlobe keloids. REFERENCES 1. Kelly AP. Keloids and hypertrophic scars. In: Parish LC, Lask GP, editors. Aesthetic dermatology. New York: McGraw- Hill, 1991: Cheng LH. Keloid of the ear lobe. Laryngoscope 1972; 82: Stucker FJ, Shaw GY. An approach to management of keloids. Arch Otolaryngol Head Neck Surg 1992;118: Cosman B, Crikelair GF, Ju DM. The surgical treatment of keloids. Plast Reconstr Surg 1961;27: Oluwasanmi JO. Keloids in the African. Clin Plast Surg 1974;1: Alhady SM, Sivanantharajah K. Keloids in various races. A review of 175 cases. Plast Reconstr Surg 1969;44: Arnold HL Jr, Grauer FH. Keloids: etiology, and management by excision and intensive prophylactic radiation. Arch Dermatol 1959;80: Shons AR, Press BH. The treatment of earlobe keloids by surgical excision and postoperative triamcinolone injection. Ann Plast Surg 1983;10: Sallstrom KO, Larson O, Heden P, Eriksson G, Glas JE, Ringborg U. Treatment of keloids with surgical excision and postoperative X-ray radiation. Scand J Plast Reconstr Surg Hand Surg 1989;23: Mercer DM, Studd DM. "Oyster splints": a new compression device for the treatment of keloid scars of the ear. Br J Plast Surg 1983;36: Fulton JE Jr. Silicone gel sheeting for the prevention and management of evolving hypertrophic and keloid scars. Dermatol Surg 1995;21: Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol 1993;19: Berman B, Flores F. Recurrence rates of excised keloids treated with postoperative triamcinolone acetonide injections or interferon alfa-2b injections. J Am Acad Dermatol 1997;37: Lee Y, Minn KW, Baek RM, Hong JJ. A new surgical treatment of keloid: keloid core excision. Ann Plast Surg 2001;46: Lawrence WT. Treatment of earlobe keloids with surgery plus adjuvant intralesional verapamil and pressure earrings. Ann Plast Surg 1996;37: Converse JM, Stallings JO. Eradication of large auricular keloids by excision, skin grafting, and intradermal injection of triamcinolone acetonide solution. Case report. Plast Reconstr Surg 1972;49: Hatoko M, Kuwahara M, Shiba A, Tada H, Okazaki T, Muramatsu T, et al. Earlobe reconstruction using a subcutaneous island pedicle flap after resection of "earlobe keloid". Dermatol Surg 1998;24: Berman B, Bieley HC. Keloids. J Am Acad Dermatol 1995;33: Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hypertrophic scars: a comprehensive review. Plast Reconstr Surg 1989;84: Friedman RM. Abnormal scars. Sel Read Plast Surg 1995;8: Ollstein RN, Siegel HW, Gillooley JF, Barsa JM. Treatment of keloids by combined surgical excision and immediate postoperative X-ray therapy. Ann Plast Surg 1981;7: Norris JE. Superficial x-ray therapy in keloid management: a retrospective study of 24 cases and literature review. Plast Reconstr Surg 1995;95: Sclafani AP, Gordon L, Chadha M, Romo T 3rd. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature. Dermatol Surg 1996;22: Stashower ME. Successful treatment of earlobe keloids with imiquimod after tangential shave excision. Dermatol Surg 2006;32: Singleton MA, Gross CW. Management of keloids by surgical excision and local injections of a steroid. South Med J 1971;64: Kiil J. Keloids treated with topical injections of triamcinolone acetonide (kenalog). Immediate and long-term results. Scand J Plast Reconstr Surg 1977;11: Barton RP. Auricular keloids: a simple method of management. Ann R Coll Surg Engl 1978;60: Salasche SJ, Grabski WJ. Keloids of the earlobes: a surgical technique. J Dermatol Surg Oncol 1983;9: McCoy BJ, Diegelmann RF, Cohen IK. In vitro inhibition of cell growth, collagen synthesis, and prolyl hydroxylase activity by triamcinolone acetonide. Proc Soc Exp Biol Med 1980;163: Murray JC. Scars and keloids. Dermatol Clin 1993;11: Vol. 21, No. 3,